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67 y/o M presents to the ED with a chief complaint of mild generalized abdominal pain. The pain in dull in nature, non-radiating, without alleviating or exacerbating factors. Denies F, N/V, diarrhea, or trauma. The pt has a PMHx of DM and HTN and is complaint with medications.

What's the diagnosis?

Emphysematous CholecystitisEmphysematous cholecystitis is an uncommon variant of cholecystitis. It is more common in diabetic elderly males and half of the patients are acalculous. Patients present with symptoms similar to cholecystitis and the physical exam often mild and the patient is no toxic appearing. This occurs in approximately 1% of patients with cholecystitis and has a mortality rate around 15%.

Diagnosis is made by ultrasound or CT. Broad spectrum antibiotics should be initiated (Unasyn or Zosyn +/- Flagyl) and the most common organisms are Clostridium or Escherichia coli. This is a surgical emergency. As ALiEM reminds us abdominal pain in elderly patients can be tricky; half of older adults with abdominal pain are admitted and of those 30% require surgery during their hospitalization.

Remember: atypical is typical, be wary of a benign exam, a picture is worth the cost, and know your surgeons!

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